MEDICARE: MISS JESSICA ERIN ELLIS R.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN189320	GA
2	163W00000X	Registered Nurse	1-107940	AL

General Provider Information

NPI Number	:	1356529358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JESSICA ERIN ELLIS R.N.

Provider Business Mailing Address
First Line	:	306 PELHAM ST
Second Line	:
City	:	CHICKASAW
State	:	AL
Zip	:	36611-2410
Country	:	US
Telephone Number	:	205-902-4928
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 BETHANY WOODS DR
Second Line	:
City	:	TEMPLE
State	:	GA
Zip	:	30179-3574
Country	:	US
Telephone Number	:	205-902-4928
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/01/2008
Last Update Date	:	02/01/2008

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